Bilateral Coordination: The Gateway to Successful Movement | Part 2

In Part 1 of this series, we discussed an overview of bilateral coordination, its importance and how it falters in Parkinson’s Disease (PD).

Now, we’ll discuss strengthening the pathways for those with PD with exercise.

Steps To Incorporating Bilateral Coordination Into Your Exercise Program

Clearly, the brain is a work of art when you consider the “architecture”, the “highway” of nerves required to communicate with the rest of the body, to the final outcome of the original thought or idea. ANY kind of “road block” is going to hinder an individual from completing tasks as simple as writing or buttoning a shirt. And for the person living with PD, this includes walking, bathing, driving, communicating, dressing, well, about every Activity of Daily Living (ADL) that you can conceive.

BUT… never fear, the PD Fitness Specialist is prepared to address these matters of the brain with some challenging YET fun activities to promote improved motor control!

I won’t lie, you may see smoke coming out of the “fighters” ears but the incredible sense of accomplishment at the completion of the drill will be worth it.

Always begin with the fundamental question of program design. What are the needs of my private clients and fighters? What are their common issues?  They definitely need to work on:

Strength (7 foundational movements)

• Lunge
• Squat
• Pull
• Push
• Carry
• Hinge
• Rotate

NOTE: I encourage Fitness Professionals (FP) to start with the most basic form of each Foundational Movement before progressing to a more challenging version. I have learned that repetition and exercise phases are a necessary part of any fitness program, similar to the human development process.

Your program should also include cardiovascular endurance, agility (footwork/hand-eye), cognitive challenges, fine motor drills, balance/gait drills — ALL which incorporate Bilateral Coordination challenges that provoke the brain to enhance:

1. Neuro-protection to preserve at-risk dopamine neurons.
2. Neuro-repair to improve damaged “circuitry”  and rewire the brain.
3. Neuro-Adaptation that trains the brain to move without conscious awareness of each move such as walking .

Yes, this requires the Fitness Professional to sit down and develop a program that is constantly evolving as the abilities and needs of the client change BUT it can be done. For example, to address gait and incorporate an additional Bilateral Coordination drill that will challenge your client(s) mental focus, try the following progressive drill.

NOTE: Step one is a fantastic way to help a person living with Parkinson’s Disease safely transition out of a “freezing of gait” moment.

Criss-Cross Applesauce (Stand in squat stance)-

1. Cross the right hand to the left shoulder.
2. Cross the left hand to the right shoulder.
3. NOW, cross the right hand to the left knee.
4. Cross the left hand to the right knee

Have your client(s) say “Criss-Cross Applesauce” while performing the drill. This will address hypophonia problems and assist in maintaining a strong beat..

Once they have achieved this version, have them progress to the next level….

Criss-Cross Applesauce with Marching Knees

1. Cross the right hand to the left shoulder.
2. Cross the left hand to the right shoulder.
3. NOW, cross the right hand to the left knee BUT lift the knee to meet the hand as if marching.
4. Cross the left hand to the right knee and lift knee to meet hand as if marching.

To add complexity to the drill, have your clients tap the marching knee onto a step or bosu.

Once they have achieved this version, have them progress to the next level….

Criss-Cross Applesauce with A Forward Lunge

1. Cross the right hand to the left shoulder.
2. Cross the left hand to the right shoulder
3. NOW, cross the right hand to the left leg AS you lunge forward.
4. Come back to start position.
5. Cross left hand to the right leg AS you lunge forward
6. Return to start and repeat drill

To add complexity to the drill, have your clients perform a diagonal lunge or a lateral step.

This is just one example of how you can incorporate Bilateral Coordination into a movement we do all day every day! Walking! And if you work with people living with Parkinson’s Disease, then expect their learning time to vary but with repetition and encouragement, they will conquer this drill and be excited to try the next.

Which leads me to share with you the results I have experienced in my Parkinson’s Disease Wellness Center in Nashville and Franklin, Tennessee.

CASE STUDY – RESULTS!

“Susan” is 62 years old and was diagnosed 17 years ago which classifies her as Young Onset Parkinson’s Disease.  Susan had the DBS surgery 10 years ago and although the DBS initially provided relief of tremors and dyskinesia, over time fine motor skills, drooling, hypophonia, balance/poor posture — leading to numerous falls — has become an issue. She is also blind in one eye which limits her spatial awareness, decreases balance and mobility, all of which makes living independently even more challenging. Additionally, the hypophonia had led her to become 80% non-verbal. To answer questions she either nodded yes/no or shrugged her shoulders if she didn’t know the answer.

When we began working 1:1 together, my first priority was to address her posture/gait, as she was stooped forward and shuffling, leading to multiple falls each week. So, in addition to a dynamic warm-up with large ROM drills to properly prepare her body from head to toe, strength training, boxing and cycling, obstacle courses and more, I taught her the “Criss-Cross Applesauce” drill. The first several sessions, Susan had to complete the drill 5x between other warm-up exercises AND march while tapping her hand to the opposite knee when we moved to a new station or machine. She also had to speak the words “Criss-Cross Applesauce” when performing the drill to address her hypophonia.

The first session, Susan could not make the connection that her hand was to tap the opposite shoulder or knee. I had to manually move her hands and say the words with her. By the end of the first session, she was only able to complete the drill at a slow tempo, but that was ok, she did it! She left the gym that day with homework to practice the “Criss-Cross Applesauce” drill three times a day for 5 repetitions. I also assigned marching in place while tapping the hand to the opposite knee 60x twice a day.

The second session, I noticed a significant difference in her timing and coordination. For the first set, I still needed to “mirror” her while she did the “Criss-Cross Applesauce” drill, but overall, Susan was able to complete the drill 3 out of 5x correctly. When Susan would move to a different location, I had her march and tap her hand to the opposite knee. We counted how many steps it took to make it to the next station with the goal of trimming 10-15 steps off the next round. To do so, I had her focus on making precise connections between her hand and opposite knee as well as stomping her foot when stepping. By the end of the session she was able to trim 5-10 steps off between stations.  She completed the session with the same homework as before.

The third session is when I started to notice some fantastic improvements. Susan walked into the gym marching and tapping the hand to the opposite knee. She was able to cover more ground with fewer steps and the best part was that stomping her foot was helping her step with increased assurance. That equates to fewer falls! Additionally, transitioning station to station took less time and she was able to lift her knee higher than the previous sessions.

The “Criss-Cross Applesauce” drill still required me to “mirror” her but she did all 5 reps correctly and her hand/shoulder and/or hand/knee connection was more actively engaged. We continued to perform the drill between each exercise or cardio drill and by the end of the session, she spoke with clarity and increased volume, her stride length had increased, posture was more vertical and her confidence soaring. She even told me a joke!

The exciting results I experienced with Susan have also been experienced in my group exercise classes for Parkinson’s Disease. “Fighters” report that their forward/lateral movements, executive functioning skills, and balance have improved since incorporating Bilateral Coordination drills into our program.

Closing

The brain, in all its complexity, is a beautiful work of architecture. You, the Fitness Professional, have the “blue-prints” at your fingertips and together we can weave together bilateral movements to enhance the lives of those with Parkinson’s strengthening their bodies, mind and spirit and above all giving hope.

To assist you in learning how to create exercises that incorporate Bilateral Coordination into your program, I have included additional videos below demonstrating examples of exercises. (I would like to give credit to Dr. Irv Rubenstein, MedFit author & advisory board for the use of two of his drills in the video.)

This video comes from Dr. Jacob Weiss of handeyebody.com

Become a Parkinson’s Disease Fitness Specialist!

Check out Colleen’s online course on MedFit Classroom….

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Co-Written by Colleen Bridges, M.Ed, NSCA-CPT and Renee Rouleau.

Colleen Bridges is the author of MedFit Classroom’s Parkinson’s Disease Fitness Specialist course. Renee Rouleau is a PhD student at the Jacobs School of Biomedical Sciences, University at Buffalo.

References

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2. Plotnik, M., & Hausdorff, J. M.. (2008). The role of gait rhythmicity and bilateral coordination of stepping in the pathophysiology of freezing of gait in Parkinson’s disease. Movement Disorders, 23(S2), S444–S450. https://doi.org/10.1002/mds.21984
3. Rutz, D. G., & Benninger, D. H.. (2020). Physical Therapy for Freezing of Gait and Gait Impairments in Parkinson Disease: A Systematic Review. PM&R, 12(11), 1140–1156. https://doi.org/10.1002/pmrj.12337
4. Son, M., Han, S. H., Lyoo, C. H., Lim, J. A., Jeon, J., Hong, K.-B., & Park, H.. (2021). The effect of levodopa on bilateral coordination and gait asymmetry in Parkinson’s disease using inertial sensor. Npj Parkinson’s Disease, 7(1). https://doi.org/10.1038/s41531-021-00186-7
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6. Magalhães, L.C., Koomar, J.A., Cermal, S.A. (1989, July) Bilateral Motor Coordination in 5- to 9-year old children: a pilot study. The American Journal of Occupational Therapy. Volume 43 Number 7.
7. Piek, J.P., Dyck, M.J., Nieman, A., Anderson, M., Hay, D., Smith, L.M., McCoy, M., Hallmayer, J., (2003) The relationship between motor coordination, executive functioning and attention in school-aged children. Archives of clinical neuropsychology. Elsevier’s Ltd. doi:10.1016/j.acn.2003.12.007
8. Roeber, B.J., Gunnar, M.R. and Pollak, S.D. (2014), Early deprivation impairs the development of balance and bilateral coordination. Dev Psychobiol, 56: 1110-1118. https://doi.org/10.1002/dev.21159
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11. Tseng, Y., & Scholz, J. P. (2005). Unilateral vs. bilateral coordination of circle-drawing tasks. Acta Psychologica, 120(2), 172-198.